August 28th, 2010  Cross-posted from “Sacramento Street Psychiatry“.
In dynamic psychotherapy, patients often say how hurt and victimized they feel as a result of unkind judgments or criticisms by others:
“My coworker called me a hypocrite!”
“My mother told me I neglect her by not visiting enough.”
“My husband complains I’m too self-centered.”
Although sharing such complaints with a caring listener is basic human nature, in therapy it is also recognized as a defense mechanism called externalization. A fundamental tenet of psychotherapy is that change comes from within. The hurtful coworker, mother, or husband is not present in the room, and cannot be influenced directly by the discussion. It is the patient’s reaction that can be examined and perhaps modified.
I tend gently to move things along in therapy, as opposed to letting them unfold at their own pace. I often question this in myself, sometimes wondering if I am too results-oriented. On balance, though, I believe it saves time, money, and tedium for both of us if I focus on issues that can actually make a difference. With this in mind, I don’t let externalizations just sit there. I playfully illustrate how harsh judgments only sting if the patient accepts or endorses them at some level: The hurt is really self-criticism, and the solution is really a new self-appraisal.
If I accuse you of being a dirty rotten Martian, it isn’t apt to have much impact. You may question my sanity, but you are not put on the defensive or moved to offer a spirited rebuttal. Nor do you engage in sober soul-searching to assure yourself I’m mistaken. You already know you are not a Martian, so the putdown rolls off your back.
In contrast, what if I accuse you of being selfish? This charge is harder to dismiss. We are all selfish to some degree; it’s a judgment call where to draw the line between self-interest on the one hand and self-sacrifice on the other. Moreover, as Sigmund Freud describes in Civilization and its Discontents, humans are able to live together in society because we repress many self-gratifying urges into the unconscious. We are, in other words, more selfish (and narcissistic, and greedy, and hypocritical, and childish…) than we like to think.
The criticisms that sting are the ones that stir up our own self-doubts. Maybe we are hypocritical, neglectful, self-centered. Perhaps our shameful defect has been exposed. This is what calls up anxiety, reactive anger, and defensiveness.
Such self-criticism is unpleasant when made conscious in therapy. Yet this is the path toward change. For the problem is not in the external world after all. It resides in the mind of the person in the therapy room, a person who now more clearly sees where his or her troubling feelings originate.
I really do use the Martian example all the time in my work with patients. It’s a thing of joy to watch how something so apparently frivolous can shift the focus from unhelpful externalization to honest insight.
July 26th, 2010  Earlier this year, blog commenter TK wrote:
“Isn’t this the greatest countertransference, in this age of fee-for-service psychotherapy as opposed to psychotherapist-on-salary: How do I work around my own economic motivation in deciding whether to continue with a patient or terminate?
“In other words, how does one reconcile the consistent economic incentive to keep a client coming back to your office, particularly when one is being paid by the therapy hour instead of by salary? After all, there’s always something to work on, to improve, to understand better…
“In other, other words — and this is only partially tongue-in-cheek….Is there truth to the adage that you don’t ever want to see any psychotherapist who has openings in their practice?” 
In a similar vein, a reader named Cynthia more recently posed a challenge:
What would you think about a patient asking a therapist at the outset of therapy to report to her at the start of each session how many client/patient hours you have scheduled for that week? That would give her real insight into what’s going on in the therapist’s practice, and would help determine how important it is for the therapist for her to keep coming back. Would you personally be willing to provide that kind of information?
To me, this seems far more important to know than any therapist personal life information that would arouse normal patient curiosity.
I replied to Cynthia’s comment, noting that such disclosure might appear to be a useful consumer tool not only for therapy clients, but also for anyone hiring an electrician or plumber, a lawyer, a music teacher, or a medical doctor. For each of these, financial incentive may be a factor in determining how “important” it is for the customer, client, or patient to return. However, none of these service providers offer this information, and presumably all would consider the question intrusive and overly suspicious.
Of course, even having this concrete information may lead to different conclusions. An underemployed service provider may be relatively unskilled, and/or more desperate for income. As TK offers: “you don’t ever want to see any psychotherapist who has openings in their practice.” On the other hand, overly busy providers may not be available at all, may be hard to schedule, or may not give you their full attention. Nor is busy-ness always a sign of quality. Some providers market themselves better, or offer faddish services that are popular at the moment. All of this applies equally well to hiring a house painter or a psychotherapist.
Seeing a therapist is different than hiring a plumber or painter, though. Popularity (e.g., high ratings on Yelp, or on one of the dedicated rating sites for doctors or therapists) is no guarantee of a good personal connection with you as an individual. Rapport with a therapist is more idiosyncratic and subtle than that, a matter of chemistry. Also, since therapy quality is more subjective than the quality of a plumbing or paint job, the impressions of others may not be as reliable.
However, even if we agree that a busy therapist is apt to be a good therapist, TK and Cynthia share a somewhat different concern. They worry that therapist economic incentive may lead to unnecessarily prolonged therapy. “Isn’t this the greatest countertransference…?”
In a sense, yes, the wish to be paid for providing psychotherapy is the greatest countertransference. There are important ancillary gratifications of the work — the satisfaction of helping troubled people, the intellectual challenge — but being a therapist is, first and foremost, a livelihood. A therapist who lacks the money to buy food, or who faces eviction or mortgage foreclosure, is not in a position to “bracket” his or her own needs and put the patient’s first. I confess that when I first opened a private office in 1995, retaining my first few patients mattered more to me than it should have. While I don’t believe I harmed anyone, or kept anyone in treatment longer than needed, the economics loomed large in my mind.
However, this situation passed quickly. I cannot speak for all therapists or all psychiatrists, but on the whole we make a decent living whether our practices are full or not. Patients come and patients go; the economics surrounding any one patient is not a major consideration. As in many features of the therapy relationship, the dynamics feel weightier to the patient than to the therapist. This makes good sense, as the patient only has one therapist, but the therapist has a number of patients. (And transference magnifies these issues for the patient more than countertransference does for the therapist.) Thus, a vacation of either party usually matters more to the patient. Fees and money issues usually matter more to the patient, and so forth.
As I read the comments of TK and Cynthia, I recognize a core of realistic concern that the therapist may be biased by economic incentive. But barring specific evidence of desperation or money grubbing on the part of the therapist, I can’t help but think of this as a concern magnified by transference. Economic incentive is the default situation when hiring anyone for anything. Do you worry that your car mechanic, tax preparer, or personal trainer is just stringing you along for the money? We all need to keep our eyes open, but there’s a point at which one’s natural suspicion can give way to trust and a sense of security. Healthy relationships reside in the sweet spot between gullibility on the one hand, and paranoia on the other. If suspicion persists, whether in therapy or elsewhere, there is a problem. Maybe the other person gives subtle signs of untrustworthiness. Maybe one’s own “trust meter” (transference) is a bit askew. Figuring this out is itself the stuff of dynamic therapy; it can shed light on one’s relationships inside and outside the therapy office.
June 26th, 2010  Reposted from Sacramento Street Psychiatry.
Sometimes an unruly character disrupts the surrounding peace and quiet. Loud, gruff words and ill-considered behavior mar the scene. Onlookers cringe, awaiting the impending destruction. For this beastly fellow is bound to break something: wreck a friendship or relationship, make a workplace intolerable. All the worse if the setting harbors sensitive souls with feelings easily hurt. It’s a disaster waiting to happen.
We might say this person is a “bull in a china shop.” In this image a powerful animal threatens fragile items of great value. Its untempered impulses — hunger, lust, anger — may bring the edifice crashing down at any instant. Even the natural movements of a relatively calm bull may clumsily destroy order and beauty all around. The message is clear. This bull needs to be controlled, tranquilized, restrained if necessary. Or magically turned into something innocuous, a house-cat perhaps. As a last resort, it must be led out of the china shop without delay, before more damage is done.
Certainly there are interpersonal situations described very aptly this way. However, in my psychotherapy work I’ve repeatedly encountered this scenario turned on its head. I’ve begun to look at the phrase differently: Maybe the bull isn’t always the culprit.
The phrase “bull in a china shop” usually implies that the china shop was there first. The bull wandered in uninvited. But suppose we set up the scene another way. Picture a bull grazing in an open field. Yes, it’s a big powerful animal, and maybe it’s a bit clumsy. But it isn’t hurting anyone; it is living in peace.
Then imagine someone sneaks up on this bull — and builds a china shop around it. The animal suddenly finds itself constrained, unable to move without hearing the crash of broken porcelain. Its natural movements are now seen as destructive, as the china is surely at risk. Yet it isn’t quite right to blame the bull.
In human relationships, the person with socially disturbing behavior hasn’t always caused the problem. This manifests most obviously in work with children, who frequently express parental distress through their own misbehavior. Even in adults, an apparently calm and mature person may quietly stir up someone else, who then becomes the “identified” patient (a term from family therapy implying that one or more other parties, equally worthy, evaded this identification).
In individual therapy, patients often build a case in calm, reasoned tones that their partners, close relatives, or coworkers are unruly, uncaring, even beastly. They describe emotional ruffians who threaten them without cause. It can take months, or longer, before a patient’s own role comes to light. This may take the form of passive-aggression, i.e., goading the other into lashing out. [Some links describing passive–aggressive behavior.]
There is no small measure of passive hostility in building a china shop around a bull. All too often we observers arrive late upon the scene, only to witness the wild animal haplessly bumping into fragile dinnerware. It can take a long time to realize that the bull was just being a bull, and that the root problem was the apparently innocent bystander who constructed a china shop the bull was almost sure to topple.
June 19th, 2010  I apologize for the stagnant blog of late. I’ve been working on an idea or two that hasn’t jelled yet. Meanwhile, I ran across a familiar yet troubling occurrence the other day: The use of a psychiatric hold on an inpatient with no psychiatric disorder but who was refusing life-saving medical treatment.
My comments are limited to California, as each state has its own laws about psychiatric holds, a.k.a. involuntary civil commitment. The Lanterman-Petris-Short (LPS) Act, signed into law by Governor Ronald Reagan in 1969, made California the first state to employ a “dangerousness” standard to justify psychiatric holds. Prior to this, mental patients were generally committed on the basis of “need for treatment.”
Dangerousness is defined in the LPS law as danger to self (usually interpreted as intentional self-harm or suicide risk, not mere recklessness), danger to others, or grave disability (inability to provide for one’s own food, clothing, or shelter). For LPS provisions to apply at all, the alleged dangerousness must be the result of a mental disorder or chronic alcoholism. The LPS Act is part of the state Welfare and Institutions Code, sections 5000 and following. The initial 72-hour hold in California is called a “5150” as it is authorized in section 5150 of the WIC. Here is a brief history of California mental health law.
Virtually all other states adopted psychiatric commitment laws similarly based on dangerousness after the US Supreme Court ruled in O’Connor v. Donaldson, 422 U.S. 563 (1975) that, “There is…no constitutional basis for confining such persons involuntarily if they are dangerous to no one.”
Let’s turn now to a non-psychiatric setting, the general medical-surgical hospital. Some hospitalized patients cannot make informed medical choices, or they may express unpopular, “crazy” opinions. At one extreme are patients who arrive unconscious and cannot express a choice at all. In the typical emergency situation, doctors and nurses reasonably assume such a patient wants to receive lifesaving treatment, and proceed accordingly. Other patients may be delirious, in great pain, or suffering from a brain injury or stroke. They may express preferences that make no sense to the medical professionals, choices that seem “crazy.” (Questions about decision-making capacity almost never arise when the patient agrees with the doctor, only when there is disagreement.)
These situations have nothing to do with psychiatric illness. It is well recognized that some patients lack the capacity to make medical decisions while in the throes of severe illness or injury. As with the unconscious patient, lifesaving treatment proceeds with assumed consent. No one lets a confused delirious patient stagger out of the hospital just because he lurches blindly in that direction.
More challenging ethical dilemmas arise when a refusing patient is simply uneducated or from another culture. When I was a medical intern, I saw an elderly Filipino man with intestinal bleeding. He had never been seriously sick before, and did not understand Western medicine. He refused blood transfusion on the theory that “the more you put in, the more will leak out.” The senior medical resident requested a psychiatry consult to declare the man incompetent to make such decisions. (This was a mistake, as I’ll explain shortly.) He then received transfusions against his will. Soon thereafter the patient refused surgery needed to stop the bleeding. The surgeon proclaimed he would never operate on an unwilling patient — but in an odd twist, when the patient lapsed into unconsciousness, he was “no longer objecting” and the surgery proceeded. The patient died in the post-surgical ICU, never having regained consciousness.
This sad case highlights a few important points I’ll just touch on here. First, assessment of medical decision-making capacity is not a special skill of psychiatrists. All physicians are supposed to do this routinely (albeit usually implicitly). Internists need to know whether their patients can give informed consent for medical treatments, and surgeons should likewise assess the capacity of their patients to consent to surgery. “Competence” is an overarching legal status decided by a court, not by medical or psychiatric assessment alone. Perhaps the most obvious point: Once a patient’s consent or refusal is considered valid, its ethical force doesn’t diminish when the patient falls asleep or lapses into unconsciousness.
Now, how does the “5150” apply in the non-psychiatric hospital setting? Hardly at all. Patients with severe mental illness are sometimes hospitalized for unrelated conditions, and occasionally meet dangerousness criteria for a 5150 hold while receiving medical treatment. But the more common situation is the misuse of the “5150” to prevent an apparently lucid patient from refusing lifesaving medical or surgical treatment and leaving the hospital. This is startlingly common — it startles me, anyway — and happened just the other day at my hospital.
It should be obvious why the 5150 cannot be used this way. First, it only applies to a situation in which a mental disorder or chronic alcoholism leads to dangerous behavior. Second, refusal of lifesaving medical treatment is not “danger to self” as the law is normally understood. Third, even a legitimate 5150 hold only compels three days of psychiatric evaluation and protective custody; it says nothing about forcing medical or surgical (or even psychiatric) treatment on anyone.
The solution is for physicians to assess the medical decision-making capacity of their own patients. Where available, a hospital ethics consult can clarify the relevant issues, but this is usually optional. Patients who possess medical decision-making capacity have the right to refuse treatment and to leave the hospital if they wish, even if they die as a result. Those who lack such capacity can be treated, like the comatose or delirious patient, with assumed consent. However, a superior court determination of incompetence to make medical decisions is required to force non-emergency medical or surgical treatment. LPS law is silent on these matters.
April 24th, 2010  My fellow psychiatrist and blogger Dr. Daniel Carlat has an article in this weekend’s New York Times Magazine. “Mind Over Meds” is a memoir of Dr. Carlat’s growing realization that psychiatry can’t be done well in 15-20 minute medication visits, that talking to patients as people is important too.
I’m generally a fan of Dr. Carlat. His blog is one of the few listed on my blogroll (the short list of links over there on the right of this page). He writes well, and I share his skeptical attitude toward overzealous promotion of psychiatric drugs to our profession and the public. “Mind Over Meds” is a good article: Carlat reviews the swing from the “brainless” psychiatry of early 20th-century psychoanalysts, to the “mindless” psychiatry of today, where symptoms are treated with medications and the patient may be lost in the process.
This is all on target, and I appreciate how Dr. Carlat is willing repeatedly to make it personal and write about revisions in his own thinking — as he did in this prior NY Times Magazine article, also well worth reading. The gist is that psychiatry has painted itself into a corner by limiting itself largely to psychopharmacology, i.e., medications, and ceding psychotherapy — understanding the patient as a person — to other mental health professionals.
Unfortunately, “Mind Over Meds” goes off the rails in two ways. The less important is a passage that I have to believe is just badly worded, as it seems to denigrate psychologists and other non-psychiatric therapists:
Like the majority of psychiatrists in the United States, I prescribe the medications, and I refer to a professional lower in the mental-health hierarchy, like a social worker or a psychologist, to do the therapy. The unspoken implication is that therapy is menial work — tedious and poorly paid.
A couple of early commenters have already chided Dr. Carlat for this “mental health hierarchy” language. Discussing whether mental health professionals constitute a hierarchy is beyond my scope here, but I believe Dr. Carlat is well aware that the expertise of many psychologists (for example) to do psychotherapy surpasses his own. In fact, he has recently taken a contrarian position in favor of granting psychologists prescribing privileges. I doubt he meant this talk of hierarchy as a putdown, but he should have been more clear.
The bigger gaffe is that the article ultimately calls for psychiatrists to do “some sort of psychotherapy… when our patients need more from us than just medication.” Dr. Carlat seems to be satisfied with a little support here, a few extra minutes of listening there. However, that isn’t psychotherapy except in the most meaningless, hand-waving sense. That is just listening to one’s patients, something every doctor should do, from dermatologists to orthopedic surgeons. I hate to say it, but it’s no wonder health plans won’t pay for that. It used to be part of the job, not something extra.
Psychiatrists have a lot more going on than mere doctor-patient rapport — or at least we used to. Even psychiatrists who choose not to conduct psychodynamic therapy still learned, or should have learned, about psychodynamics, an intellectual and historical cornerstone of our field. A psychiatrist’s work needs to be psychodynamically informed even if he or she only prescribes medication. As the most obvious example, a dynamic understanding may shed light on a patient’s medication non-compliance and help to address it. Even better, a dynamic understanding of the patient may obviate the need for medications at all. (To those who argue that psychodynamics has been supplanted by cognitive-behavioral therapies, I note that Dr. Aaron Beck, the founder of cognitive therapy, was a psychoanalyst first. Even cognitive therapy works better if it is conducted by a psychodynamically informed therapist.)
Dr. Carlat should have gone farther. Psychiatry needs to retake the position that we strive to understand and heal the mind from the molecule on up (a position taken by Freud, among many others). It is true that this encompasses a dauntingly wide spectrum, from psychopharmacology to psychological treatment, and beyond that to social and cultural influences. As physicians we are the only mental health discipline with the training to appreciate the whole span; other professions, like clinical psychology, may have more in-depth knowledge and treatment skills regarding a particular part of this spectrum. Of course, any given psychiatrist may choose not to practice at all of these levels — probably cannot, given the sweeping range. But it is the essence of psychiatry to know about the full spectrum, and either offer whatever treatment is needed at any level, or refer the patient to a professional who can provide it.
It is necessary but not sufficient to see a patient behind the symptoms, to listen. It is also incumbent on psychiatrists to conduct real psychotherapy, dynamic or otherwise, when sitting with a patient for 50 minutes and charging for it. Ceding “real” therapy to others has diminished our field and has turned most psychiatrists into technicians. “Mind Over Meds” is the right title for a much deeper topic.
March 20th, 2010  I attended a very good lecture this week on contemporary views of countertransference. It inspired me to write a brief overview of the concept here, with more to follow.
To understand countertransference, it helps to tackle transference first. As I’ve discussed previously, transference was a word coined by Sigmund Freud to label the way patients “transfer” feelings from important persons in their early lives, onto the psychoanalyst or therapist. Psychoanalysis was specifically designed to encourage transference. Intentional opacity and non-disclosure by the therapist promotes transference; the patient naturally makes assumptions about the therapist’s likes and dislikes, attitude toward the patient, life outside the office, and so forth. These assumptions are based on the patient’s experiences with, and assumptions regarding, other important relationships, such as childhood relations with parents. In this way the patient’s formative dynamics are re-created in the therapy office for both participants to observe. Patients discover that some of their assumptions about others, and themselves, are unfounded or outmoded and do not serve them well. This is an important type of insight that can lead to lasting psychological change.
Freud realized that transference is universal, and therefore could occur in the analyst as well. He did not write much about this, except to say that “countertransference” could interfere with successful treatment. The analyst experiencing countertransference should rid himself of these feelings by having further analysis himself.
Since the 1950s, psychoanalysts and psychodynamic therapists have held a more benign view of countertransference. It is no longer seen as an impediment to treatment (at least not inevitably), but instead as important data for the therapist to use in helping the patient. Countertransference can serve as a sensitive interpersonal barometer, a finely tuned instrument in the field of social interaction. For example, a therapist who feels irritated by a patient for no clear reason may eventually uncover subtle unconscious provocations by the patient that irritate and repel others, and thereby keep the patient unwittingly lonely and isolated.
In using countertransference this way, the therapist must consider multiple sources of his or her feelings. Some feelings, positive or negative, may be evoked by the patient. These are particularly helpful ones to notice, especially when the cause is not immediately obvious, as in the example just given. Often, however, feelings may be stirred up by irrelevant characteristics in the patient (e.g., the patient physically resembles the therapist’s sibling or spouse), by the prior patient, or by factors unrelated to therapy (e.g., bad traffic getting to the office, a quarrel at home, an upcoming vacation). This strongly argues for dynamic therapists to pursue such therapy themselves: It “tunes the instrument” to better distinguish countertransference evoked by the patient, versus similar feelings that arise from other causes. Freud’s advice for analysts to seek additional analysis themselves in the face of countertransference is wise, although not for the reasons he gave.
I teach psychiatry residents to go through a mental checklist whenever they become conscious of possible countertransference:
(1) Is this feeling characteristic, i.e., does the resident have it much of the time? If so, it may say a lot about the resident, but probably nothing about his or her patient.
(2) Is the feeling triggered by something unrelated to the patient? Feelings caused by hunger, one’s personal life, bureaucracy in the medical center, and so forth are not useful data for helping the patient.
(3) Is the feeling related to the patient in an obvious way? Feeling irritation toward a patient who is screaming obscenities and viciously destroying the office is countertransference of a sort, but not very illuminating. And finally,
(4) Is the feeling uncharacteristic of the therapist, a reaction to one particular patient, and yet the exact trigger is not immediately obvious? These are the most helpful feelings to notice in oneself, as they often shed light on subtle yet important dynamics in the patient.
Countertransference is not always helpful. Particularly when it is unexamined — or, worse, unrecognized — it can indeed interfere with effective treatment. This can occur even with positive countertransference, as when a therapist is so entertained by a patient’s jokes that the underlying bitterness is ignored, or when an attractive patient is never challenged because the therapist desperately yearns to be liked. More often, though, countertransference is problematic when it is negative. The therapist feels bored, irked, paralyzed, or contemptuous in the presence of a particular patient. It is the therapist’s job to recognize these feelings and deal with them. Occasionally a therapist must refer the patient to a colleague when the original therapist’s countertransference is unmanageable. Fortunately, in most cases these uncomfortable feelings, once recognized by the therapist, can not only be understood but also used constructively in the treatment.
January 29th, 2010  Cross-posted from “Sacramento Street Psychiatry“
The New York Times blog called “Well” recently asked: “Will Olympic Athletes Dope if They Know It Might Kill Them?” The answer is surprisingly clear: Many would if they could. In bi-annual surveys conducted from 1982 to 1995, researcher Bob Goldman asked elite athletes whether they would take a drug that guaranteed them a gold medal but would also kill them within five years. Again and again about half the athletes said yes, they would accept such a trade-off. This question has come to be known as the Goldman dilemma, and for most of us the high rate of acceptance is shocking. In contrast, a 2009 study asked the same question of the Australian general public, and only two of 250 respondents reported they would accept this Faustian bargain.
Sports success obviously matters more to dedicated athletes than to the rest of us. But what about success in general? Or happiness? Would you give up years of life in exchange for more happiness, in whatever form that may take?
I imagine many of us would say no, especially if the choice were posed concretely (e.g., blissful happiness for five or ten years, then death). We live life “for better or worse”; it feels like our duty to accept what life deals out. Yet nearly all of us engage in activities that make us happier in the moment at the possible cost of a shortened lifespan. From tasty but unhealthy foods to exciting but dangerous extreme sports, from alcohol to tobacco, our actions seem to show that longevity is not our highest priority. Memorable experiences are a particularly cost-effective way to buy happiness, but many of these experiences carry risks.
One factor that colors our willingness to trade longevity for happiness is how we deal with probability. The Goldman dilemma is posed as a sure thing, whereas the risks we face in real life are likelihoods. Genuine satisfaction in the moment is weighed against potential risk later on. The latter does not feel quite real, even if its likelihood is very high. We rationalize our choices by imagining we will be lucky.
Even more important is that we choose without consciously choosing. No one decides, cigarette by cigarette, how many minutes of life to trade away for each puff. Motorcycling and skiing would lose their luster if sober calculations of risk were undertaken before each run. We maximize our happiness by means of selective inattention.
The most shocking thing about athletes’ acceptance of the Goldman dilemma is that they admit, out loud, a value that the rest of us share only silently, awkwardly, and ambivalently: We often do value quality over quantity in life. A life devoted exclusively to safety and longevity strikes many of us as unsatisfying. Perhaps we will make better — not necessarily safer — choices if we consider consciously the trade-offs we already make.
Would you trade years of life for happiness? Chances are excellent that you already do.
Illustration: Happiness and Longevity (Fu Shou). Calligraphy by Tao Gui, Ming dynasty (1547), China.
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